Acceptance and Commitment Therapy: A Transdiagnostic Model of Behavior Change

1. Acceptance and Commitment Therapy: A Transdiagnostic Model of Behavior Change Jason B. Luoma, Ph.D., Steven C. Hayes, Ph.D. University of Nevada, Reno Frank W. Bond, Ph.D., Goldsmiths College, University of London Akihiko Masuda, M.A., University of Nevada, Reno

2. Why pay attention to transdiagnostic processes of change? • Without transdiagnostic processes of change, behavioral technologies are likely to gather into an ever expanding pile with no means for simplification or possibly advancement (there are currently how many hundred DSM diagnoses…) • It is unlikely that scientists and practitioners will be able to maximize the efficacy of our interventions if the most proximal psychological processes are not understood. • If processes that cut across diagnostic categories can be found, clinician training might be made more efficient and effective

3. DSM is based on topography • Topographically-defined clusters of behavior/symptoms may not tell us much about etiology or maintenance of these patterns • Behaviors that appear different in form may have similar functions • Examples: • Eating to avoid feeling lonely (BED/Bulimia?) • Not getting out of bed to avoid feeling lonely (Depression?) Common function? avoidance Implication - Behaviors that look different may actually be the same when viewed functionally.

4. DSM is based on: The Assumption of Healthy Normality • By their nature humans are psychologically healthy • Abnormality is a disease or syndrome driven by unusual pathological processes • We need to understand these processes and change them

5. ACT: Human Suffering is Ubiquitous and Normal Lots of data - high rates of serious suicidal ideation, high lifetime prevalence of “disorders”, prejudice, divorce, abuse, etc. Hypothesis: Normal human psychological processes, particularly side effects of language, result in much suffering (Hayes, Barnes-Holmes, Roche, 2001) “Disorder-specific” processes can be exacerbated by normal language processes

6. Example: ACT and Psychotic Symptoms • Can ACT help with what a “disorder specific” pathological process? • Bach & Hayes (2002): 80 S’s hospitalized with hallucinations and/or delusions randomized to either ACT or TAU • 4 hours of ACT; all but one session inpatient • Recently replicated by Gaudiano and Herbert (2004) with similar results

7. Impact on Rehospitalization 1.0 ACT .9 Proportion Not Hospitalized .8 .7 .6 Treatment as Usual 40 80 120 Days After Initial Release

8. Processes of Change: Symptoms 100 ACT 75 Percentage Reporting Symptoms 50 Control 25 Pre Post Phase

9. Processes of Change:Believability 80 Control Literal Believability of Psychotic Symptoms (0-100) 60 ACT 40 Post Pre Phase

10. Relational Frame Theory Stimulus Equivalence: An Example of the Core Verbal Process Lemon Derived Function (e.g., taste) Very early on (<14 months old or so), a human will begin to derive... Function (e.g., taste)

11. These Three Relations Are the Basis for Suffering • When frames of coordination (previous slide), time or contingency, and comparative frames become part of a person’s repertoire, problem solving is made possible, but also: • Comparison to an ideal • Worry about imagined futures • Social comparison / prejudice / stigma • Self-loathing • Social inhibition (e.g., fear of negative evaluation)

12. Because of Relational Frames Self-knowledge of painful events is painful Emotional pain The actual abuse causes emotional pain Description Abuse Later, just describing or thinking about the event causes emotional pain, so thinking about it is avoided Emotional pain Description

13. Implications of Relational Frames • At least two destructive processes result naturally from language: • Experiential Avoidance • The tendency to attempt to alter the form, frequency, or situational sensitivity of historically produced negative private experience (emotions, thoughts, bodily sensations) even when attempts to do so cause psychological and behavioral harm • Based originally on natural processes of language but is amplified by the culture • Cognitive Fusion/Literality • The domination of derived functions (i.e., those based on language) over other response functions even when this process creates psychological and behavioral harm

14. Two Processes Aimed at the Root Cause • Acceptance involves • Encouraging the direct moment-to-moment contact with previously avoided private events (that functionally need not be avoided) as they are directly experienced to be, not as they “say they are” • E.g., interoceptive exposure; Gestalt exercises; challenging a control agenda • Cognitive defusion involves • a change in the normal use of language and cognition such that the ongoing process of thinking is more evident and the normal functions of the products of thinking are broadened. • Similar to mindfulness techniques (as seen in MBCT, DBT) clients are taught to observe thoughts without becoming entangled in them; a thought is understood, but it is also heard as a sound, seen as a habit, or dispassionately observed as an automatic verbal relation

15. ACT Outcomes to Date • At least 31 completed studies (25 published), including 11 randomized controlled trials • Problems: pain, anxiety, psychosis, depression, eating disorders, conduct disorder, prejudice, substance abuse, smoking, stress, burnout, school performance, stigma, OCD, diabetes • Variable in lengths and emphases • Always better than control; often has performed better than active treatment comparators

16. ACT Mediational Results • Diabetes - ACT compared to diabetes education - diabetes-related acceptance shown to be a mediator of self-management behaviors (Gregg, 2004) • Smoking Cessation - ACT compared to nicotine patch - smoking-related acceptance shown to be mediator of smoking cessation outcomes (Gifford, Kohlenberg, Hayes et al., 2004) • Workplace stress - ACT compared to Innovation Promotion and waitlist - general acceptance (AAQ) mediated general mental health outcomes (Bond & Bunce, 2000) • Counselor Stigma and Burnout - ACT compared to multicultural training and education - believability of stigmatizing thoughts mediated outcomes on burnout and frequency of stigma (Hayes et al., 2004).

17. Process of Change Outcomes Believability of problem-relevant thoughts is reduced by ACT • depression (Zettle & Hayes, 1986) • psychosis (Bach & Hayes, 2003; Gaudiano, 2004) • polysubstance abuse (relative to control; Bissett, 2001) • counselor stigma and burnout (Hayes et al., 2004) Acceptance is increased by ACT • chronic pain (McCracken, Vowles, & Eccleston, in press) • diabetes self-management (Gregg, 2004) • mathematics anxiety (Zettle, 2003) • parents of autistic children (Blackledge, 2004) • self-stigma in substance abuse (Kohlenberg, Luoma, et al., 2004) • smoking cessation (relative to control; Gifford et al., 2004) • workplace stress (Bond & Bunce, 2000)

18. Experimental Psychopathology Studies • Positive results comparing defusion vs. control instructions on reducing discomfort and believability of negative self-relevant thoughts (Masuda et al., 2004) • in 2 cold pressor/1 analogue pain task experiments, individuals given an acceptance-based rationale were able to tolerate higher levels of pain than those given a control rationale (Gutierrez, Luciano, & Fink, 2004; Hayes et al., 1999; Takahashi et al., 2002) • in 2 experiments studying tolerance of CO2 enriched air, participants (normals/panic disordered) given an acceptance based rationale reported less distress and were more willing to try the task again (Eifert & Heffner, 2003; Levitt, Brown, Orsillo, & Barlow, 2004)

19. Meta analysis of Correlational Studies • 21 studies with 51 correlations investigated the relationship between the AAQ and quality of life (QOL) outcomes (e.g., depression, anxiety, PTSD, trichotillomania, stress, pain, job performance, and negative affectivity). • The Q statistic indicated that the magnitude of these 51 associations varied significantly. Subsequent analyses indicated that these correlations could be separated into two groups, in each of which the magnitude of the correlations was significantly similar or homogenous. • Group 1: 26 correlations, with a total sample size of 6,024: Medium size effect: aggregated correlation 0.28 (95% confidence interval: 0.26 – 0.31). • Group 2: 25 correlations, with a total sample size of 4,817: Large size effect: aggregated correlation of 0.54 (95% confidence interval: 0.52 – 0.56)